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PARACENTESIS: ANTICOAGULATION AND COAGULOPATHY

Posted on July 26, 2019October 4, 2019 by admin

In 2017, the ACC published, with the aid of other professional societies
consensus bleeding risk associated with various procedures [1]. The ACP rated
Paracentesis as low bleeding risk.

While the ACC/ACP recommendations were geared toward elective / planned
procedures in patients with atrial fibrillation, the thought process behind an
individuals treatment plan peri-procedurally is the same.

 1. Assess the patient’s inherit bleeding risk (i.e. HAS-BLED)
 2. Consider the procedural bleeding risk
 3. Put this information in context of the urgency of the procedure.

In this context, we believe most paracenteses will be sufficiently low risk that
reversing or holding anticoagulation is not warranted.

--------------------------------------------------------------------------------

COAGULOPATHY, THROMBOCYTOPENIA

Per The American Association for the Study of Liver Diseases (AASLD) 2012
guidelines, “bleeding is sufficiently uncommon, the routine use of prophylactic
fresh frozen plasma or platelets before paracentesis is not recommended” (Class
III, Level C) [2].

One thing to note is these recommendations are based on two outpatient studies
with very few patients with extreme coagulopathy or thrombocytopenia (e.g. only
1 patient with platelets <20K [3] or lowest platelet count 54K [4]).

Regardless, bleeding episodes were so rare and did not correlate with laboratory
parameters; hence the author comments “there is no data-supported cutoff of
coagulation parameters beyond which paracentesis should be avoided” [2].

 1. Doherty JU, et al. 2017 ACC Expert Consensus Decision Pathway for
    Periprocedural Management of Anticoagulation in Patients With Nonvalvular
    Atrial Fibrillation: A Report of the American College of Cardiology Clinical
    Expert Consensus Document Task Force. J Am Coll Cardiol. 2017 Feb
    21;69(7):871-898.
 2. BA Runyon; AASLD. Introduction to the revised American Association for the
    Study of Liver Diseases Practice Guideline management of adult patients with
    ascites due to cirrhosis. 2012. Hepatology. 2013 Apr;57(4):1651-3.
 3. CM Grabau, et al. Performance standards for therapeutic abdominal
    paracentesis. Hepatology. 2004 Aug;40(2):484-8.
 4. BA Runyon. Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med.
    1986 Nov;146(11):2259-61.

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